“The drug that brings people back”: naloxone availability in Maryland

Opioid-related overdoses have continued to increase in the United States since 1990 and remain one of the leading causes of death among several diverse populations. These trends are reflected in Maryland where rates of deaths from overdoses has been increasing dramatically. Naloxone, a safe and effective opioid antagonist, is one of the few substances that can combat overdose without risk of abuse or harm. However, when naloxone is only available to health care professionals, it’s impactfulness is not fully realized. Currently when a person overdoses, peers are only likely to call 911 10% to 56% of the time due to fear of police presence and legal retribution.Effective June 1st, 2017, anyone can get naloxone at Maryland pharmacies without a prescription by mandate of a statewide standing order. By allowing and enabling people to administer naloxone without emergency personnel presence, people are able to save lives without the risk of punitive legal response. This also allows the public safety sector, including Baltimore Fire and Police Departments, to be able to focus their care on more stable patients. With local and national governmental support in combating this epidemic, major pharmacy chains Walgreens and CVS already carry over the counter naloxone in Baltimore. In addition to pharmaceutical availability, the Turning Point Clinic and Maryland Addiction Recovery Center offers support and training to anyone seeking naloxone. However, the social stigma associated with drug addiction and this prescription remains for those with opioid addiction and their friends and families.

As health care professionals we firmly support timely availability of naloxone in pharmacies free any form of stigma that opioid users so frequently face. Maryland Pharmacist Association executive director Aliyah Horton saidthat pharmacists wish to discuss administration and “why they need it in the first place”. We urge the Maryland Pharmacist Association partner with the Maryland Department of Health and Mental Hygiene to develop competency trainings for pharmacists and best practices for dispensing naloxone in a way that makes customers feel safe and respected so that this critical public health policy is utilized to it’s fullest potential. With the additional 50 million dollars from Governor Hogan, we believe this is a viable option that offers a well-rounded response towards this crisis.

5 Responses to ““The drug that brings people back”: naloxone availability in Maryland”

This is quite an interesting, but appropriately-timed issue to raise, as opioid overdose has been in the national headlines of late. Definitely a urgent public health issue that needs to be addressed. The proposed solution, based on the Maryland example, is quite helpful, as a strong case can be made to reduce any barriers to accessing the naloxone, the ‘remedy’ to opioid overdose. The problem becomes 1) how can the public and pharmacists be totally assured that this opioid OD ‘rescue drug’ can be used properly and in a timely manner without the supervision of a health care professional (like a doctor or nurse), and 2) will facilitating access to naloxone actually reduce opioid use or its inappropriate prescribing by physicians, or are there other factors contributing to the latter problems?

Thank you for bringing up the issue! Making effective help available in a medical emergency is desirable no matter what the causes are. Therefore making naloxone available to peers and family in an emergency situation due to opioid overdose makes sense and should be supported. However, people need to be trained and educated as Naloxone is given through intravenous or intramuscular injection or intranasally, and possible secondary risk factors, such as an unknown heart disease, could come into play.

We as the public health professional need to think further. How does the availability of an antidote influence the dynamics of personal relations? There is a high comorbidity of drug addiction and personality disorder that also have an effect on how emergency situations arise and are dealt with.

Opioid addiction is an ugly disease that is often accompanied by loss of decent behavior, i.e. crime and exploitation of oneself and others. Preventing death from overdosing opioids through self-administered naloxone should not further detach opioid drug users from society but lead towards more understanding and destigmatization by reaching out to them.

Naloxone as part of “a first aid kit” for opioid drug users and their peers is necessary in times of the opioid crisis in the United States. And still, one hopes for better times, less lonely, were in a case of emergency the aim of a society is to provide professional care within due time.

This is a very interesting post and I am especially interested because intranasal naloxone will be introduced for the first time with a proper device in the European Market this year. It is intended for emergency use for known or suspected opioid overdose as manifested by respiratory and/or central nervous system depression at home or other non‑medical setting or in a health facility setting. For this reason, intranasal naloxone should be carried by persons at risk of, or likely to witness such events (requiring proper training or information provided to them). The nasal spray has the potential to remove the psychological and policy barriers which can prevent availability of existing injectable forms of naloxone for emergency administration in the vital first minutes following an opioid overdose. The nasal spray could be administered even under difficult conditions and is, crucially, much more suitable for wide-scale pre-provision to the high-risk opioid users and people who are likely to witness an opioid overdose, such as relatives, friends and peers. The rationale for the development of intranasal naloxone builds on the background of “TAKE HOME NALOXONE” programs and improves on current improvised intranasal naloxone use. The product has been developed to combine the advantages of an effective dose of naloxone with user-friendly intranasal administration, in a form that can be given by anyone (medically-trained or otherwise) needing to help a patient suffering from opioid overdose in the vital few minutes before emergency healthcare can be provided. We have had several discussions regarding the appropriateness of this intranasal administration and also on the educational materials that would be needed. The device used has some security measures that will not allow more than 2 puffs. Most importantly, it will be reiterated that this does not substitute proper medical care in an emergency setting. The point raised with this blog post is extremely important because the pharmacist will have a very important role when dispensing this product. Information provided will be crucial for this program to work under real world settings. The idea of providing this competency to pharmacists under formal training should be encourage across States and other geographical regions, such as Europe once the drug is officially marketed. You will find several evidence in favor of IN use (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4042052/pdf/AMS-10-22713.pdf) but also the importance of stakeholders (such as pharmacists) being properly involved is highlighted by the existence of limitations to this intranasal approach (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4863654/pdf/nihms784430.pdf).

These are great measures that the state of Maryland has put in place, but further steps will be needed to inform the potential users of this life saving medicine about its availability. In addition, we should call on manufacturers and the State to offer this drug for free and provide access to it through other points of distribution. The financial and and stigma barriers will be tough to overcome for individuals most in need of this lifesaving tool.

Increasing access to naloxone is an important facet of the overall strategy for responding to the opioid-overdose epidemic. Given the current crisis, there’s good reason to consider naloxone a basic life support measure, similar to AEDs (automated external defibrillators) that allow people without medical backgrounds to act rapidly in emergency situations to save lives in the event of cardiac arrest. The 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care support providing opioid overdose response education to persons at risk for overdose or those in close contact with such persons, and algorithms have been developed for opioid-associated life-threatening emergencies. (https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/). Information about how to obtain and use naloxone should be made readily available to the general public as well as through targeted trainings.

A standing order is one good idea, but as mentioned in comments above, Maryland could also consider other ways to expand availability of naloxone, such as supplying it via health departments, and directly to family or friends of those at risk for overdose. Cost could be an obstacle to access for some, and this will likely need to be addressed too. Naloxone alone won’t solve the opioid crisis, but it can save lives and offer another chance for recovery.